Kim Y, Chen AH, Keith E, et al. "Not perfect, but better: primary care providers' experiences with electronic referrals in a safety net health system."

Kim Y, Chen AH, Keith E, et al. Not perfect, but better: primary care providers' experiences with electronic referrals in a safety net health system. J Gen Intern Med 2009 May;24(5):614-9.
BACKGROUND: Electronic referrals can improve access to subspecialty care in safety net settings. In January 2007, San Francisco General Hospital (SFGH) launched an electronic referral portal that incorporated subspecialist triage, iterative communication with referring providers, and existing electronic health record data to improve access to subspecialty care. OBJECTIVE: We surveyed primary care providers (PCPs) to assess the impact of electronic referrals on workflow and clinical care. DESIGN: We administered an 18-item, web-based questionnaire to all 368 PCPs who had the option of referring to SFGH. MEASUREMENTS: We asked participants to rate time spent submitting a referral, guidance of workup, wait times, and change in overall clinical care compared to prior referral methods using 5-point Likert scales. We used multivariate logistic regression to identify variables associated with perceived improvement in overall clinical care. RESULTS: Two hundred ninety-eight PCPs (81.0%) from 24 clinics participated. Over half (55.4%) worked at hospital-based clinics, 27.9% at county-funded community clinics, and 17.1% at non-county-funded community clinics. Most (71.9%) reported that electronic referrals had improved overall clinical care. Providers from non-county-funded clinics (AOR 0.40, 95% CI 0.14-0.79) and those who spent > or =6 min submitting an electronic referral (AOR 0.33, 95%CI 0.18-0.61) were significantly less likely than other participants to report that electronic referrals had improved clinical care. CONCLUSIONS: PCPs felt electronic referrals improved health-care access and quality; those who reported a negative impact on workflow were less likely to agree. While electronic referrals hold promise as a tool to improve clinical care, their impact on workflow should be considered.

Survey of primary care providers (PCPs) to assess the impact of electronic referrals on workflow and clinical care.

Tools Used
Type Clinic
Primary care
Type Specific
Internal medicine
not applicable
Urban and suburban
Other Information
24 safety net clinics - hospital based primary care, county funded community and non-county funded community clinics, all PCPs have option of referring adult patients to San Francisco General Hospital (SFGH).
Type of Health IT
Health Information Exchange (HIE)
Type of Health IT Functions
The electronic referral system integrates the existing EHR and clinical data into electronic referrals. These are centralized and triaged by designated subspecialty. Referring providers complete an electronic template to which existing relevant EHR information is automatically appended. Subspecialists review requests within 72 hours and choose to (1) schedule next available regular appointment, (2) schedule an urgent appointment or (3) do not schedule. When reviewers do not schedule an appointment, they request additional information or suggest alternative management. Referring and reviewing providers can communicate until issue is resolved - either schedule an appointment or agree that patient does not need one. When appointment is granted, this decision is electronically transmitted to the clinic scheduler, who makes the appointment. The hospital EHR system then generates a letter to the patient and an email to the referring provider alerting him/her to the appointment. The electronic referral portal keeps a database of all submitted referrals.
Context or other IT in place
The SFGH electronic referral system includes integration of existing EHR demographic and clinical data into electronic referrals, triage of referrals, and back-and-forth communication between referring providers and a subspecialist reviewer.
Workflow-Related Findings
Providers were concerned that electronic referrals would disrupt workflow which could have impaired the perception of improved care. The authors found that a significant proportion of Consortium clinic (non county-funded community clinics) providers reported taking longer to submit electronic referrals than other providers; the length of time for submission was independently associated with lower satisfaction with overall clinical care.
More than 6 min spent per referral predicted lower odds of agreeing that clinical care had improved, even after adjusting for clinic setting.
Study Design
Only postintervention (no control group)
Study Participants
PCPs with referring privileges to SFGH working in one of three safety net clinic systems: (1) SFGH-based primary care, (2) community based county funded health centers that share a common EHR with SFGH, (3) local non-county funded community health centers. PCPs were defined as either Family Medicine or Internal Medicine physicians or mid level providers (nurse practitioners or physician assistants) who see adults and practice in primary care clinics. A total of 298 participated (81% response rate).